Diagnosis: Suicidal ideation, Paranoia, Depression

Treatment: Behavioral health inpatient hospital admission

The insurer denied coverage for continued behavioral health inpatient hospital admission.

The denial is upheld.

This is a female patient with a history of anxiety disorder, trauma and paranoid schizophrenia who was admitted for inpatient mental health treatment due to suicidal thoughts to end life without a plan, depressive symptoms, increased paranoid thoughts, and anxiety including trauma issues. The patient reportedly was the victim of sexual trauma. The patient was in outpatient psychiatric treatment with a psychiatrist and therapist. The patient lived with her mother and siblings. The patient had no reports of past suicide attempts or illicit substance use. During this inpatient stay, treatment included sertraline and risperidone. The patient reportedly improved and was discharged on day 8 of admission.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment. In this case, as of day 7 of admission, there were no reports of further serious psychotic symptoms such as paranoid delusions, and there were no reports of hallucinations or disorganized behavior, suicidal or homicidal ideation, intent, or plan, manic symptoms, aggressive, threatening, self-injurious, or agitated behavior, withdrawal symptoms or acute medical instability. Notes reported that the patient was feeling fine, was pleasant, interacting and participating well, and her paranoia resolved. There were no reports of suicidal thoughts or severe depressive symptoms then.

Based on the review of the medical record, as of day 7 of admission, there were no reports of acute or severe mental health or behavioral symptoms that required 24-hour acute hospital treatment. There was also no specific evidence that the patient was considered an imminent danger to self or others, and there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital treatment setting or that could not be achieved in a less restrictive level of care as of then. Thus, continued inpatient psychiatric treatment from day 7 to day 8 of admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the continued behavioral health inpatient hospital admission from day 7 to day 8 of admission should be upheld. The medical necessity is not substantiated.